11832 POST THIS CARD NEAR FRONT OF BUILDING
' PFRMI+NUMBER
CITY OF. CUPERTINO 11832
INSPECTION DIVISION
JOB INSPECTIO RECORD
I
'II'�J(-� PERMIT EXPIRATION
JOBADORESS � ' I✓', T# LOT#
PERMIT EXPIRES IF WORK
OWNER CONTRACTOR IS NOT STARTED WITHIN
INSPECTION D TE INSPECTOR INSPECTION RECORD 180DAYS OFPERMIT ISSU-
FOUNDATION 2—I 0—a' ANCE OR 180 DAYS FROM,
IASTCALLEDINSPECTION.
' UFER �O
PREGUNITE
PERMIT VALIDATI(1`
� ••-
POUR NO CONCRETE UNTIL ABOVE HAS BEEN SIGNED
.UNDERGROUND-/SLAB city Of
PLUMBINGCG'Ag�lnO,
ELECTRICAL ISSUANCE DATE
BLDG, ELECT. PLG. MEG .
MECHANICAL ' 0/ 0 ❑ 0
00 NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED BUILDING PERMIT
WINFORMATION
WOOD FLOOR
VALUATION SIFT.
PLUMBING
MECHANICAL
PERMIT T
ELECTRICAL. /
FRAMING
IE TYPE 0 SIR,
INSULATION
OCC,GROUP RES. ITS
_ PLACE NO SUBFLOOR UNTIL ABOVE HAS BEEN SIGNED - -
ROOF - SO.Fi.fLOOR AREn TOTAL ACREAGE
DIAPHRAGM '
RES
BUILDING USE OJ,o13 r
' .IND CON PB
APPLY El
NO ROOFING UNTIL ABOVE HAS BEEN SIGNED Q^
ASSESSORS PARCEL NO.
!� ROUGH
PLUMBING
GTRACT NO.
AS TEST PARCEL NO.
MECHANICAL.
ACC.DATE ACG FILE NO.
ELECTRICAL FINALS DATE INSP.
FRAMING �{
SAN ZONING ENc.51rENo.
INSULATION PLUMBING L
GAS
FIRE SPR INK ENERGY T 24
MECHANICAL v NE] v NE]NO WORK UNTIL ABOVE HAS BEEN SIGNED HEATING
FLOOD ZONE A.L.U.C. .
LATH—INTERIOR - ELECTRICAL
LATH—EXTERIOR FIRE DEPT. v N� Y ❑ N�
SHEETROCK GRADE FEE SUMMARY
SHEAR INTERIOR' BUILDING
SHEAR EXTERIOR TEMPORARY APPROVALS BUILDING
FIREWALLS ELECTRIC PLAN CHECK
GAS FEE
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SIGNED IOCCUPANCY SEISMIC FEE
OCCUPANCYOF BUILDING IS NOT PERMITTED UNTIL BUILDING FINAL IS SIGNED BY BUILDING INSPECTOR. MICROFILM
ARRANGE FOR INSPECTION BY PHONING 252-4505, ELECTRIC
w ONE WORKING DAY BEFORE REQUIRED INSPECTION. PLUMBING
• 0 PLEASE GIVE JOB ADDRESS WHEN PHONING:
Z MECHANICAL
— SEE PERMIT FOR EXPIRATION DATE —
CONST.TAX
IMPORTANT!
PLEASE READ REVERSE SIDE BEFORE TOTAL
CALLING FOR FINAL INSPECTION.
OFFICE COPY
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
•� BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT
ADOREay — r ^J>.� N 11832
n I z) /✓�(((/ BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'S PLAN CHECK VALIDATION
�L NA V. ELECTRIC PERMIT FEE
E
�a HaMeAcoHs r� �I �}1 UTLETS-SWITCHES-RECEP 10.00/1.00
/ Ko SW SON IL CO, LIC.ND. b3/( LIGHTING FIXTURES 10.00/1.00
ADDRESS OR's APPLIANCES-RESIDENTIAL 4.00
ADDRESS I ��)�,f•/��
LLVIL, PHOrvE ('�/V,l PANEL$ 10,00 GATE OF APPLICATION
/ ARCHITECT PLAN CHECK FEE
OR PANELS (OVER 200 AMP) 20.00
ENGINEER
m.No SIGNS TRANS. 3.00
ARCH.OR END.
�( ADDR s SPECIAL CIRCUIT 5.00 I�p, ALIDATION
/— Q iI EMP.METER OR POLE INS. 20.00 OCTp n
APPLICANT'S MOTORS SEE FEE SCH. C f 2 7 1986
ADDRESS
SERVICE CHANGE 20.00 thy"
Foo Z.
LICENSED CONTRACTORS DECLARATION C(" Of CIIQQrtIntl
<it w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
aN commencing with Section 7000)of Division 3 of the Business and BLD ELECT. PLG. MECH.
F N Us to"I
Cod a—n y license is in 1'u111bresv •li:Ct .7 ❑ ❑ ❑
z O In— icense Iss Lic.Number :C Y -
4 m F Date — Contractor
m¢a OWNER-BUILDER DECLARATION BUILDING PERMIT
— 0 u, INFORMATION
MISC.— REFER TO ORD
F.
3 u I hereby affirm that l am exempt from the Contractor s License VALUATION $/FT.
u O¢ Law for the following reason.(Sec.7031.5,Business and Professions PERMIT ISSUANCE 10.00
w i Code:Any city or county which requiresa permit to construct,alter, O DOD
X ¢r o prior to its issuance,also ELEC.CONTR. LIQ NO. ELEC. /
¢O improve,demolish, r repair any structure,p
— O LL requires the applicant for such permit to file a signed statement that TOTAL ERMIT
w$m he is licensed pursuant to the provisions of the Contractor's License
Fir Law(Chapter 9(commencing with Section 7000)of Division 3 ofthe
14 Business and Professions Code)or that he is exempt therefrom and OTV. PLUMBING PERMIT FEE
K H the basis for the alleged exemption.Any violation of Section 7031.5 1 1 STORIES TVP C NSTR.
by say applicant for a permit subjects the applicant toacivil penally ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more Ill..five hundred dollars(S500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 4.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
• property who builds or improves thereon,and who does such work FIXTURES,PER TRAP 5,00 SO,FT,FLOOR AREA TOTALACREAGE
himself or through his own employees,provided that such improve- GAS-EA.SVSTEM-1 6,00
mens are not intended or offered for sale.If,however,the building
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES INDPB Omer
prove for purpose of sale.); INDUSTRIAL WASTE INTER. 30,00 CO
❑ 1,as owner of the properly,am exclusively contracting with ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSEss 5PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a couttactons)licensed pursuant to
the Contractor's License Luw, SEWER-SAN ITARV-STORM EA.200ft/10.00
TRACT NO. PARCEL NO.
❑ lam exempt under Sec.—,BAP.C.for this WATER HEATER W/VENT 6.00
reason
Owner Date WATER SYSTEM 5.00 ACC.DATE ACC.FILE NO.
WORKERS'COMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
hereby affirm that I have a certificate of consent 10 selpinsure. ZONING ENG.SITE N0.
or a certificate of Workers'Compensation Insurance,or a certified
cop eof f5 CC.3800,Lab,G.).
P Icy No Company
0 ❑ Car Eed copy i5 hereby furnished. FIRE SPRINK ENERGY T 24
Z Z ❑ Car f ,c��o.�py�Is�fI d with he 'y mspecf vision. MISC.- REFER TO ORD.
0 Applican It+�—A� �• Y ❑ N❑ Y❑ N❑
~ In PERMIT ISSUANCE 10.00 FLOOD ZONE A.L.UC.
CC — ERTIFICA'fE OP EXEMPTION FROM WORKERS'
UJ >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG. V v
(L 0 (This section need not be completed if the permit is for one TOTAL ❑ N❑ ❑ N❑
::) Z hundred dollars IS 100)or less.)
U 0 1 certify that in the performance of the work for which this per. QTY. MECHANICAL PERMIT FEE FEE SUMMARY
IL P mit is issued,I shall not employ any person in any manner so as to
V become subject to the Workers'Compensa_tion Laws of California.
LU Date Applicant BUILDING
Q. ALTER OR ADD TO MECH. 5.00
} Go NOTICE TO APPLICANT: If,after making this Certificate of Ex-
? emption,you should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, you must forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 1Q000CF.M.) 4.00
CONSTRUCTION LENDING AGENCY AIRHANDLING UNIT(OVER IOAODC.EM.) 6.00 SEISMIC FEE / 4Ld
1 hereby affirm that there is a construction lending agency for EXHAUST HOOD(WITH DUCT) 5.00 ,
the performance of the work for which this permit is issued(Sec. HEATING UNIT(TO 100,000 B.T.U.) 8.00 MICROFILM
3097,Civ.C.).
Lender's Name
Lender's Address HEATI NO UNIT(OVER 100,000 B.T.U.19.50 ELECTRIC
0 1 certify that 1 have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information is correct. I agree to comply with all city and co only PLUMBING
ordinances and state laws relating to building construction, and BOILER-COW(3H.P..1100,000B.T.U.I 6.00
hereby authorize representatives of this city Io enter upon the BOILER-COMP (over 100,000BTU)SEE FEESCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
Cupertino against Babilities,judgments, costs and exvenses which PERMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said CiI in consequence of the
BE g of thi petmh. MECH.CONT. LIC.NO. MECH.
x /� 7-'16 TOTAL TOTAL c/LID
tgnatureo Applicant/Contractor Uate
OFFICE COPY